HEADACHES

Headaches are a nearly universal experience, with a 1 year

period prevalence of 90 % and a life time prevalence of 99 %
Most headaches are benign, but some secondary headache
can have serious. A careful history, examination, diagn-testing
 daignosed correctly

PAIN SENSITIVE STRUCTURES

Similar headaches can have different causes because there are
a limited number of pain sensitive structures.
Paradoxically, although all pain is felt in the brain, the brain
parenchyma itself is not pain sensitive. The arachnoid,
ependyma, and dura (except portion near vessels ) are also not
sensitive to pain.
Pain sensitive structures
that can cause headaches

Transmitted through the trigeminal nerve and upper cervikal segment

Intracranial structures
Dura near vessels
Cranial nerves V, VII, IX, X
Circle of willis and proximal continuations
Meningeal arteries
Large veins in the brain and dura
External to the skull
Scalp and neck muscles
Cervikal nerves and roots
Cutaneous nerves and skin
Mucosa of the paranasal sinuses
Teeth
External carotid arteries and branches
Major Categories of
Headache disorders
 Migraine
 Tension type headache
 Cluster headache
 Headache associated with head trauma
 Headache associated with vascular disorders
 Headache associated with nonvascular intracranial
disorders
Intracranial infection, Intracranial neoplasma
 Headache associated with metabolic disorders
Hypoxia, hypercapnia, hypoglycemia
 Headache or facial pain associated with disorder of
cranium, neck, eyes, ears, nose
 Cranial neuralgias, nerve trunk pain and trigminal
neuralgia
 Tension Type and Chronic Daily Headache

Episodic tension type headache (ETTH) is defined by the

International Headache Society (IHS) as recurrent episodes
of headache.
Older term that are still sometimes used : muscle contraction
headache, tension headache, stress headache, and ordinary
headache

Diagnosis
Episodic Tension Type Headache occurs with a history of at
least 10 previous headache episodes.
The headache duration is from 30 minutes to 7 days.There is
no aura or prodrome.
The pain is usually dull and is described as aching, tightness,
heaviness, pressure, soreness, band like or cap like
Management

ETTH is typically treated with aspirin and/ or

acetaminophen
Often combined with caffeine or alternatively with
nonsteroidal anti inflamatory drugs (such as
ibuprofen, napoxen sodium, or ketoprofen)
To prevent habituation and rebound the use of
combination analgesics should usually be limited to 10
events or 24 tablets or capsules.
Non medication : relaxation training, bio feed back
physical therapy
Migraine Headache
- Migraine is a recurrent, throbbing headache of vascular
origin
- Usually unilateral, opposites sides of the head may be
affected during different attack
- Prevalence female : male = 3 : 1
+ one third severely headache  disabled  bed rest

1. Classic migraine a visual aura precedes the throbbing

headache by 10-20 minutes. Prodrome consist of
migrating scotoma, or waviness and blurriness of vision
The prodrome is followed by a unilateral throbbing
headache over 1-6 hours.
Usually abates in 6-24 hours. Vomiting, nausea,
photophobia, irritability and malaise are common
2. Migraine variants
 Common migraine, the characteristic throbbing
headache occurs with out the visual prodrome of
classic migraine
Sligthly longer course than classic migraine
 Familial hemiplegic migraine. Migraine with aura that
includes hemiparesis.
Availability of a family history
 Ophtalmoplegic migraine, migraine headache paresis
n III,IV,IV  diplopia may occur during infancy
 Basilar migraine. Aura originating from brainstem,
with visuals symptoms : blurred vision, blank spots,
vertigo, tinnitus
Treatment
- General measures
• Avoid provoking factors: smoking, alcohol ingestion,
lack of sleep, stress, fatigue or the ingestion of certain
foods, especially chocolate and cheeses
• Anxiety and depression should be treated
• Oral contraceptives
- Abortive therapy
• Ergotamine may be adminisstered alone or in
combination with antiemetics, analgesic or sedative
• Isometheptene or combination (midrin)
• Dihydroergotamine (DHE) may parenteral (sq, im, or iv)
• Triptans : sumatriptans (Imitrex) 50mg-200mg/day,
nasal spray : 20-40 mg/day
- Preventive Therapy
Methysergide, beta blockers, amitriptyline,
cyproheptadine (periactin), phenytoin and calcium
channel blockers
Symptomatic therapy
• Aspirin or acetaminophen
• Severe headache : codein 30-60 mg or morpine 4-8
mg, q3-4h. Vomiting can be controlled with
promethazine
• In case severe, prolonged or unremitting migraine
(status migrainosus : prednisolon 40-60 mg/daily
combine with adequate analgesia
Cluster Headache

 A periodic, paroxysmal headache disorder.

Excruciating unilateral head pain
 Occurs in brief episodes : 15 minutes-2 hours) without
prodrome, daily for 3 weeks-3 month then remitting
month or years
 Pain is sharp, boring, piercing, facial flushing, nasal
stuffiness eye tearing usually at night may without
nausea, vomiting
Treatment
 Ergotamine, methysergide, cyproheptadine,
propanolol and prednisone
 Symptomatic : may required narcotic agents
Trigeminal Neuralgia (Tic Douloureux)

Characterized by brief, lancinating paroxysms of

pain (lasting for seconds or minutes) in the
distributions of the fifth cranial nerve
Attack occur during chewing, swallowing,
shaving, tooth brushing
Neuralgia postherpes (zooster oftalmica)
Treatment
Phenitoin, carbamazepin (tegretol) baclofen
(lioresal),and may be surgery.